Objective: Unidentified fever, headache, and gastrointestinal symptoms after endosaccular coil embolization are occasionally observed in patients with unruptured cerebral aneurysms. We defined these symptoms as post coiling syndrome (PCS) and analyzed the clinical risk factors involved.

Methods: We applied the PCS diagnostic criteria based on the scoring of symptoms, which include fever, headache, nausea, and/or vomiting. Thirty-six consecutive patients were included in this retrospective study. Systematic follow-up included clinical and blood examinations.

Results: Based on our criteria, 11 of 36 patients were diagnosed with PCS. Between patients in the PCS group and patients in the non-PCS group, we recognized significant differences in age (63.4 ± 12.5 vs. 53.8 ± 12.9, respectively; p <0.029) as patient background and in aneurysmal diameter (9.96 ± 4.24 vs. 6.48 ± 3.06, respectively; p <0.049), aneurysmal volume (242 ± 254 vs. 87.9 ± 70.1, respectively; p <0.015), total coil length (122 ± 106 vs. 39.1 ± 25.7, respectively; p <0.0021), and volume embolization ratio as aneurysmal data (41.9 ± 8.1 vs. 30.7 ± 8.5, respectively; p <0.0019). In addition, we recognized a significant difference in postoperative leukocytosis as an inflammatory factor.

Conclusions: Patient age, aneurysmal diameter, aneurysmal volume, total coil length, and volume embolization may enable the prediction of PCS.

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Objective: Contrast-induced acute kidney injury is more likely to result in various morbidities than to develop into renal dysfunction. To prevent acute kidney injury from occurring, we performed hydration therapy and administered reduced contrast medium concentrations for patients with preexisting high-risk chronic kidney disease (CKD; stage 3 or 4). The objective of this study was to evaluate the effectiveness of these procedures.

Methods: Fifty-one sites underwent carotid artery stenting. We divided the patients into two groups by CKD stage (group A: stage 1–2, group B: stage 3–4) and reduced the dose of contrast medium during the intervention for the patients in group B. Furthermore, intravenous hydration peri-intervention was performed in patients with CKD stage 3b or 4. The differences in the estimated glomerular filtration rate (eGFR) between before and after therapy, were retrospectively assessed.

Results: There was a significant difference in the two groups in terms of the dose of contrast medium administered (group A: 58.3 ml ± 18.5 ml, group B: 32.8 ml ± 21.5 ml, p <0.01). Moreover, there was a significant difference between the two groups in terms of the difference in eGFR before and after the intervention (group A: –4.87 ml ± 8.23 ml, group B: 1.03 ml ± 6.07 ml, p <0.05).

Conclusion: Our findings indicate the effectiveness of a reduction in the dose contrast medium and hydration for the prevention of renal dysfunction in high-risk CKD patients undergoing carotid artery stenting.

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Objective: To assess the selection of carotid endarterectomy (CEA) or carotid artery stenting (CAS) and the choice of embolic protection device (EPD) on the basis of a preoperative magnetic resonance (MR) plaque image such as Sp/Sm (signal intensity ratio of carotid plaque against sternocleidomastoid muscle).

Methods: Between August 2011 and August 2015, 180 patients who underwent CEA or CAS at our institution were retrospectively analyzed. CEA was selected when soft plaque was suspected by a plaque image of Sp/Sm ≥2, in contrast, CAS was indicated for patients with a surgically high-risk condition and for patients with a plaque image of Sp/Sm <2. Moreover, EPD was chosen by means of the plaque characterization such as Angioguard XP for Sp/Sm <2, Filter wire EZ or Spider FX for 2 ≤ Sp/Sm <3, and balloon (GuardWire PS/Mo.Ma Ultra) for 3 ≤ Sp/Sm. Then, we compared the peri-operative complication rate and hyperintensity rate on diffusion-weighted image (DWI) post-operatively.

Results: In 80 cases with 3 ≤ Sp/Sm, CEA was performed for 30 cases and CAS using balloon for 50 cases. In 88 cases with 2 ≤ Sp/Sm <3, CEA was performed for nine cases and CAS using Filter wire EZ or Spider FX for 79 cases. The residual 12 cases with Sp/Sm <2 were treated with CAS using Angioguard XP. The complication rate was 2.1% in CAS and 0% in CEA. Asymptomatic hyperintensities on DWI after revascularization were detected in 24% of CAS patients and 0% of CEA patients. As for EPD, 27 of 79 CAS patients treated with Filter wire EZ or Spider FX had hyperintensities on DWI and hyperintensities were mostly observed in 21 of 39 patients with 2 ≤ Sp/Sm <3 on both T1- and T2-weighted imaging, but not in 6 of 40 patients with 2≤ Sp/Sm <3 on either T1- or T2-weighted imaging.

Conclusion: The clinical outcome of patients treated with CEA was acceptable regardless of their carotid plaque components, if SAPPHIRE CEA high-risk group is accurately excluded. Considering that balloon protection should be used as EPD against soft plaque with 2 ≤ Sp/Sm <3 on both T1- and T2-weighted imaging, selection of CEA or CAS and EPD based on the MR plaque characteristics such as Sp/Sm is a useful strategy.

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Objective: The purpose of this retrospective study was to compare the therapeutic results of middle-sized or small cerebral aneurysms coiling using 10 coil (thickness, 0.0095 inch–0.012 inch) and 14 coil (thickness, 0.0135 inch) as a complex framing coil.

Methods: Fifty aneurysms (maximum size, 4 mm–10 mm) in 50 patients treated in our hospital between May 2012 and May 2015 were assigned in this study. We compared the volume embolization rate, recurrence rate, initial occlusion grade between 14 coil (25 aneurysms) and 10 coil (25 aneurysms).

Results: The mean volume embolization ratio was significantly higher (14 coil 37.5 ± 8.8%, 10 coil 32.6 ± 8.4%; P <0.05) in aneurysms coiled with 14 inch coil than those coiled with 10 inch coil. Fourteen inch coil has a higher initial occlusion grade, and lower recurrence rate than 10 coil, but these differences were not significant.

Conclusion: The use of 14 inch framing coil to embolize middle-sized or small cerebral aneurysms is more effective in terms of a higher packing ratio.

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Objective: Patients who undergo Enterprise stent (ES)-assisted cerebral aneurysm coiling require long-term antiplatelet therapy (AT). Some studies have reported that cessation or modification of AT increases the risk of cerebral infarction. The aim of this study was to evaluate whether AT can terminated without increasing the risk of ischemic events among patients who have undergone ES-assisted cerebral aneurysm coiling.

Methods: This study evaluated 9 with 11 unruptured aneurysms were confirmed to have neointima formation with the ES on follow-up angiography. Dual AT was given for ≥3 months postoperatively, then one antiplatelet agent was administered until ≥6 months postoperatively before termination of all AT. Incidences of ipsilateral ischemic events and stent occlusion after AT termination were assessed prospectively.

Results: During follow-up (mean, 32.8 months; range, 21.5–51.3 months) ipsilateral ischemic events and stent occlusion did not occur in any cases.

Conclusion: Termination of AT ≥6 months postoperatively did not result in ischemic events among patients with neointima formation after ES-assisted cerebral aneurysm coiling.

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Objective: A case in which a microguidewire unintentionally entered the anterior choroidal artery and was trapped there during embolization of a cerebral aneurysm is reported.

Case Presentations: A 69-year-old female was due to undergo coil embolization of an unruptured anterior communicating artery aneurysm under general anesthesia. After the microguidewire unintentionally entered the anterior choroidal artery, it became impossible to manipulate or withdraw it, and a craniotomy was performed to attempt its recovery. The microguidewire was seen at the origin of the left anterior choroidal artery through the vascular wall and was considered to have entered a “false” lumen. Its extraction under direct vision was impossible. Therefore, after clipping, the microguidewire was cut at the puncture site, and the stump was left subcutaneously. The patient developed cerebral infarction in the territory of the anterior choroidal artery and was transferred to another hospital after half a year. Seven years after surgery, no change was observed in the brain or at the puncture site.

Conclusion: A microguidewire unintentionally entered the anterior choroidal artery during embolization of a cerebral aneurysm, caused arterial dissection, became irremovable, and induced cerebral infarction.

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Objective: A patient with very rare traumatic pseudoaneurysms of the external carotid artery with an arteriovenous fistula in whom rerupture could be prevented by endosaccular embolization is reported as the first of such cases.Case Presentation: A 32-year-old male underwent angiography for close examination of pulsating swelling in the left cheek 4 days after bilateral mandibular sagittal split ramus osteotomy and was found to have pseudoaneurysms in the left external carotid artery accompanied by an arteriovenous fistula. To preserve the parent vessel, emergency endosaccular embolization was performed. Complete occlusion of the pseudoaneurysms and arteriovenous fistula could be achieved, resulting in complete disappearance of the symptoms and an uneventful postoperative course.Conclusion: Endosaccular embolization is considered to be useful as a preventive measure against rerupture of pseudoaneurysms of the external carotid artery with arteriovenous fistula in which preservation of the parent artery is desirable if the lesions are distant from the skin or mucosal surface.

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Objective: We report a case of mechanical thrombectomy with stent-retriever for the insular segment of the middle cerebral artery (M2). Stent was deployed on a relatively linear vessel, which was not the culprit lesion for hemiparesis, with avoidance of excessive straightening of the culprit vessel.

Case Presentations: A 66-year-old man presented with sudden onset of left hemiparesis. MRI showed no ischemic changes and intravenous administration of t-PA was started. Cerebral angiography showed occlusion at the M2 bifurcation. Recanalization was unsuccessful using mechanical thrombectomy with a Penumbra Reperfusion Catheter 3-MAX. Therefore, thrombectomy with a Solitaire FR 4.0/15 mm stent-retriever was then performed. Stent was deployed to the other straight running culprit branch to avoid linearization of morbid vessel. Flow restoration occurred immediately after stent deployment and there was no reocclusion at 10 min after deployment. The stent-retriever was then drawn back via the guiding catheter, and clots were retrieved outside the stent struts. Immediately, angiography showed complete recanalization of the parietal and central arteries, which resulted in neurological improvement.

Conclusion: In thrombectomy with a stent-retriever for acute occlusion due to a clot at the M2 bifurcation, the site at which the stent is deployed should be determined based on efficacy, with deployment in the active zone, and safety, with avoidance of excessive vessel linearization. This should result in clot retrieval outside the stent struts, as in this case.

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Objective: Anatomical factors such as aortic arch elongation or angulation in elderly patients with arteriosclerotic change often make it difficult to perform carotid artery stenting (CAS) via the transfemoral approach under proximal balloon protection (PBP). We report a novel technique of transfemoral CAS using the inner catheter exchange method for a patient with a type III aortic arch.

Case Presentations: A 78-year-old man presented with symptomatic left carotid artery stenosis. A balloon guide catheter (BGC) was needed for PBP via the transfemoral approach. Initially, the modified Simmons-shaped inner catheter could not follow the half-stiff long guidewire to the external carotid artery (ECA) by the co-axial method. Accordingly, the inner catheter was safely exchanged with a flexible JB2 catheter with the balloon of the BGC fully inflated on the way to the left common carotid artery (CCA). Following the half-stiff long guidewire and with the JB2 catheter advanced into the distal portion of the left ECA beforehand, the BGC was successfully navigated into the left CCA below the bifurcation. Further procedures were performed without any complications.

Conclusion: This technique might be useful in patients with high risk of distal thromboembolic complications in transfemoral CAS with severe elongation of the aortic arch.

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